Tag Archives: insurance fraud

Your Workers Travel Where?

07/07/17 Julius Young

A recent California Court of Appeals decision deals with the issue of how and when an insurance carrier can rescind a workers’ compensation policy.

fraud alert road sign for Californai Workers' Compensation insurance fraud articleStudies prepared for CHSWC have shown that California is plagued with a large amount of employer premium fraud (see link at the end of this post). Sometimes it may be the hiding and misrepresentation of payroll data. Or it may be misrepresentations of the nature of work done by employees.

So clarity about how and when a policy may be rescinded is critical.

In Southern Insurance Co. v. WCAB (note that the case is designated as an unpublished opinion), the misrepresentation was about the distances trucking employees would be driving.

The employer, EJ Distribution (“EJ”), filed an online application with Southern Insurance Company in December 2008. Interestingly, the application was prepared by EJ’s insurance agent. The application listed the business as “local hauling” and also that EJ’s employees did not travel out of state or in excess of a radius of 200 miles.

However, the insurance policy itself did not have an exclusion based on location of injury.

Southern was not pleased when it received a claim that an EJ trucker had hurt his back while on a trip to Tennessee for EJ.

So Southern sent a letter to EJ rescinding the policy on the grounds of material misrepresentation or concealment of material facts in the application for insurance. Southern returned the policy premium paid by EJ.

A later investigation by EJ determined that EJ had been doing trucking operations beyond 200 miles for some time, but there was a lack of specific data uncovered as to when those out of state operations actually started. So Southern apparently did not have direct proof that out of state service was underway at the time of the January 1, 2009 policy inception.

[READ FULL STORY HERE]

Using Social Media to Fight Workers Compensation Fraud

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Social media, FaceBook superhero cartoon figureMost employees are honest. A few are not. When an employee presents an un-witnessed, subjective injury workers’ compensation claim, the smart employer will encourage the work comp adjuster to verify the validity of the claim.

 Some bright, but unethical employees will present a bogus injury claim, or attempt to inflate a legitimate injury, and will think about how to cover their fraud tracks. However, most employees who commit workers’ compensation fraud do not maintain their fraudulent façade consistently throughout the course of their insurance claim. Often there is information available in social media that proves the claim is bogus or inflated. The skilled insurance adjuster can frequently uncover information about previous insurance claims or prior medical treatment, but does not have the skill, the time or the capability to do private investigator type work through all the social media sites.

Investigation Firms Are Many More Times Proficient At Obtain Social Media Information

Private investigators are many time more proficient in obtaining beneficial information from social media websites than the work comp adjuster. If the social media information available is unknown to the adjuster, it provides no value. Social media information can have a major impact on the outcome of the workers’ compensation claim, but only if it is known. For example: The employee pursuing the bogus work comp claim will frequently exaggerate his/her physical limitations. The You Tube video of the employee skiing down the most difficult ski slope this side of the Alps is beneficial in controlling the cost of the workers’ compensation claim only if the employer and the adjuster are aware of the video and have obtained a copy of it.

With the electronic age, there is a lot of information available, if the person investigating the claim has the electronic capacity and the professional expertise to locate it. While some adjusters are experienced with Facebook and Twitter, it would be a rare adjuster who would be skilled in all the social media sites. Adjusters at insurance companies, third party administrators and self-insured employers normally turn to private investigators to search the numerous social media sites for information about the employee’s true physical status. A private investigator skilled in social media searches will check thefollowing list of sites and more.

[READ FULL ARTICLE HERE]